Structure of reports

All reports should have three main sections. First, the report should begin with the patient's personal details and the reasons for which the report has been requested, together with the identity of the commissioning agency. It should also specify the relationship between the writer and the patient. If the patient is or was in the clinical care of the writer the duration of the care should be noted, and the date of the last occasion the patient was seen should be given. If a special interview had to be arranged with a patient not previously known, the duration and date of the interview should be stated. The sources of information other than the patient used to prepare the report should then be detailed, plus any other documents that have been read. Reports for civil, judicial, and child protection proceedings will also require a short paragraph on the current employment and status of the author of the report, and a note of any special experience of relevance.

The second section should describe in appropriate detail the patient's personal, social, medical, and psychiatric history, the mental state and behaviour at examination, the diagnosis and differential diagnosis, and comments upon aetiology, management, and prognosis. In almost all reports, the prognosis is the primary concern, so this should be given special attention. It is important to remember that one of the most reliable predictors of the recurrence of behaviours or episodes of illness in the future is the frequency of their occurrence in the past. Similarly, the vulnerability of the patient in the past (that is, any enduring predisposing factors and patterns of past precipitants) will tend to predict future vulnerability and the likelihood of further episodes of illness. Some mention of the past will therefore always be necessary, but in many instances this can be brief and reduced to a commentary of a few lines. But in other situations, particularly those involving civil court actions or child care proceedings, a more detailed account of the past will be necessary.

Certain aspects of the patient's past history and previous levels of functioning will need to be highlighted depending upon the purposes of the report and the nature of the questions asked of the psychiatrist. For example, if the report has been requested by an occupational physician about the fitness of a patient to return to work, then attention will need to be paid in the report to the duration of illnesses in the past and the amount of sick leave that has been taken. Detail will need to be given about the impact, if any, that the patient's ill health has had on the past to his or her capacity to work. If the report has been requested in relation to the safety of the patient to care for a child, then information will need to be given in the past history of the patient about the previous impact of the patient's illness on his or her capacity to care for children or any risks that that the patient posed to a child in the past. Life assurance and mortgage companies are likely to be particularly interested in suicidal behaviour.

The last section should contain the opinion of the psychiatrist about the specific questions posed by the commissioning agent. These questions may be unrealistically simple or there may be requests for categorical assertions of outcome that are simply not possible. The writer must avoid falling into the trap of complying with unreasonable requests about certainties. One way of avoiding this is to give opinions about risks or outcomes by stating criteria that would indicate different outcomes with different likelihoods, expressed by words such as possible, probable, and definite.

In situations where one of the variables involved in the patient's prognosis is the response of helping agencies and the availability of resources, great care must be exercised on the part of the report writer to ensure that this contingency is made clear. If possible, suggestions should be made as to how the availability of the required resources can be assured. When considering the likely impact of a future breakdown in the mental health of a patient on some other person, such as a child, consideration should be given not only to the direct impact of the illness but also to the indirect consequences and the presence or absence of other protective factors. For example, if a woman with schizophrenia lives with her parents who can safely take over the care of her child, then the impact of a further episode on that child may be much less than if she is living alone and the child needs to be removed into the care of the local authority.

An opinion is often requested on whether an accident or an act of omission such as medical negligence caused the current psychiatric disorder or disabilities of the patient. If the psychiatrist concludes that the accident or omission was definitely a contributing cause but not in itself sufficient to cause all aspects of the existing disorder and disability, then further comments will be expected on other possible contributing influences, such as predisposing personal traits, or special vulnerability to current adversities. In such circumstances, there should be an attempt to weight the contributing factors in order of their aetiological importance.

The last section of the report is usually the best place to list the sources of information used for the report, making clear distinctions between personal observations and information obtained by the writer, opinions and observations made by other team members, and written information obtained from other documents. There should always be a clear distinction between opinions based upon objective information and direct examination, and suppositions based upon interpretations, speculation, and past clinical experience. If opinions based upon research conducted by others are given, then the sources of this information should be acknowledged and referenced in the usual manner.

The language of the report should be appropriate to the commissioning agency. If the report has been requested by an occupational physician or medical officer working for a company, then it is appropriate to use accepted medical and psychiatric terminology. If the report has been requested by a civil or judicial authority, non-technical language should be used wherever possible and any medical or psychiatric terms used should be defined. At all times when writing psychiatric reports it is important to use psychiatric terms in an appropriate fashion according to a stated international classification, and to avoid idiosyncrasies.

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